Adult Health II: Cardiovascular and Respiratory (NUR 440 B)

The correct answer is:  Inhales the mist and quickly exhales.

Explanation:

When using a respiratory inhaler, the proper technique is essential for delivering the medication effectively. The client should inhale slowly and deeply when activating the inhaler to ensure the medication reaches the lower airways. After inhaling, the client should hold their breath for about 10 seconds to allow the medication to be absorbed in the lungs before exhaling. Quickly exhaling after inhaling the mist would not allow the medication to settle in the lungs properly, thus reducing its effectiveness.

Why the other options are correct:

Removes the cap and shakes the inhaler well before use.

This is the correct action. Shaking the inhaler ensures that the medication is evenly distributed and properly mixed, which helps in delivering the correct dose.

Presses the canister down with finger as he breathes in

This is correct. The client should press down on the canister to release the medication as they begin to inhale, ensuring that the medication is inhaled deeply.

 Waits 1 to 2 minutes between puffs if more than one puff has been prescribed.

This is also correct. Waiting 1 to 2 minutes between puffs allows the first dose to be absorbed before taking another dose. This is particularly important when using inhalers for bronchodilators or corticosteroids.

Summary:

The client needs to inhale slowly and deeply and hold the breath for 10 seconds after inhaling the mist, rather than exhaling quickly. This ensures the medication is effectively delivered to the lungs.

The correct answer is:  Partially compensated respiratory acidosis.

Why this is correct

pH (7.1): The pH is acidotic (normal range: 7.35–7.45). This indicates an acid-base disturbance.

PaCO2 (60 mmHg): The PaCO2 is elevated (normal range: 35–45 mmHg), indicating respiratory acidosis. This is due to inadequate ventilation, which is common in severe pneumonia and sepsis.

HCO3 (40 mEq/L): The HCO3 is elevated (normal range: 22–26 mEq/L), indicating a metabolic compensation for the respiratory acidosis. The kidneys are retaining bicarbonate to counteract the acidosis.

PaO2 (40 mmHg): The PaO2 is severely low (normal range: 80–100 mmHg), reflecting significant hypoxia, which is consistent with severe pneumonia.

This ABG represents a partially compensated respiratory acidosis because:

The primary disturbance is respiratory acidosis (elevated PaCO2).

The body is attempting to compensate by increasing HCO3, but the pH remains acidotic, indicating that compensation is incomplete.

Why the other options are incorrect:

Partially compensated respiratory alkalosis:

Respiratory alkalosis would involve a low PaCO2 (due to hyperventilation) and an elevated pH. This is not consistent with the client’s ABG results.

Compensated respiratory acidosis:

In a fully compensated respiratory acidosis, the pH would be within the normal range (7.35–7.45) due to adequate metabolic compensation. In this case, the pH is still acidotic, indicating that compensation is incomplete.

Compensated respiratory alkalosis:

Respiratory alkalosis would involve a low PaCO2 and a normal or elevated pH, which is not consistent with the client’s ABG results.

Summary:

The client’s ABG shows:

pH 7.1 (acidotic)

PaCO2 60 mmHg (elevated, indicating respiratory acidosis)

HCO3 40 mEq/L (elevated, indicating metabolic compensation)

This is a partially compensated respiratory acidosis because the primary disturbance is respiratory acidosis, and the body is attempting to compensate but has not yet normalized the pH

The other options are incorrect because they do not match the ABG findings or the clinical context of severe pneumonia and sepsis.

This acid-base disturbance reflects the client’s inability to adequately ventilate due to severe pneumonia, leading to CO2 retention and acidosis. The elevated HCO3 shows the kidneys are attempting to compensate, but the process is incomplete.

 

Correct Answer:

Ventricular Tachycardia

Explanation of Ventricular Tachycardia (VT)

Ventricular tachycardia (VT) is a life-threatening arrhythmia originating in the ventricles, characterized by:

Wide and rapid QRS complexes (>120 ms).

No visible P waves (atria are not effectively contributing to cardiac output).

Regular, fast rhythm (typically 100–250 bpm).

The ECG in the image shows wide QRS complexes at a rapid rate, making ventricular tachycardia the most likely diagnosis.

Why the Other Options Are Incorrect

 Ventricular Fibrillation (VF

VF ECG Features:

Chaotic, irregular waveforms. No identifiable P waves, QRS complexes, or T waves. No organized electrical activity, leading to immediate cardiac arrest.

Why This ECG Is NOT VF: The rhythm in the image is organized and regular, whereas VF is completely disorganized.

Atrial Flutter

Atrial Flutter ECG Features:

“Sawtooth” pattern of flutter waves in leads II, III, and aVF. Regular atrial activity, often with 2:1, 3:1, or 4:1 conduction to the ventricles.

Why This ECG Is NOT Atrial Flutter: The QRS complexes are wide, which suggests ventricular origin. Atrial flutter typically has narrow QRS complexes unless there is an underlying conduction issue.

Normal Sinus Rhythm

Normal ECG Features:

Regular rhythm with clear P waves before each QRS complex. Narrow QRS complexes. Rate between 60–100 bpm.

Why This ECG Is NOT Normal Sinus Rhythm: The rate is too fast and the QRS complexes are wide and abnormal, ruling out normal sinus rhythm.

Summary

The ECG shows a rapid, regular, wide-complex tachycardia, which is diagnostic of ventricular tachycardia (VT). This is a medical emergency requiring immediate intervention.

The correct answer is:  "I will take the medication with food."

Explanation:

Theophylline (Theo-Dur) is a bronchodilator used to treat chronic airflow limitation (CAL), including chronic obstructive pulmonary disease (COPD) and asthma. It works by relaxing the muscles of the airways, improving airflow, and decreasing the work of breathing. Taking theophylline with food may decrease the absorption of the drug, which can reduce its effectiveness. Theophylline is usually recommended to be taken on an empty stomach for optimal absorption unless the client experiences gastric upset. Taking it with food may alter how well the medication works, so this statement indicates a need for further teaching.

Why the other options are correct (Does not Need Further Teaching)

"I will take the medication on an empty stomach."

This is correct because theophylline is generally taken on an empty stomach to ensure optimal absorption and effectiveness. If the client has gastrointestinal upset, they may need to take it with food, but it is typically better absorbed without food.

 "I will continue to take the medication even if I am feeling better."

This is correct because theophylline is a medication used for long-term management of chronic airflow limitation. It is important to continue taking the medication regularly to prevent symptoms and avoid exacerbations, even if the client is feeling better.

"Periodic blood levels will need to be obtained."

This is correct because theophylline has a narrow therapeutic index, meaning that the difference between an effective dose and a toxic dose is small. Periodic blood levels are necessary to monitor the drug's effectiveness and prevent theophylline toxicity, which can lead to serious side effects such as arrhythmias, seizures, and vomiting.

Summary:

The client’s statement "I will take the medication with food" indicates a need for further teaching, as theophylline is ideally taken on an empty stomach for optimal absorption. The other statements correctly reflect the necessary precautions and the long-term management approach required for clients taking theophylline for chronic airflow limitation.

Correct Answers: 

Weaning in the morning

Limiting activities during weaning

Placing in high-Fowler's position

Explanation

Weaning in the morning

 Weaning is generally more successful in the morning because the patient is typically more alert and rested. This may help the patient tolerate the process better, as fatigue from the night can affect their ability to participate in weaning efforts.

Limiting activities during weaning

 Limiting activities helps the patient conserve energy and prevents excessive stress or exertion, which could hinder the weaning process. By reducing activity, the body can focus more on respiratory function and recovery.

Placing in high-Fowler's position

 The high-Fowler's position (sitting upright) is beneficial for improving lung expansion and enhancing respiratory mechanics. It can also help improve oxygenation, which is crucial during the weaning process.

Why The Other Options Are Incorrect

Coaching on talking during weaning

Coaching the client to talk during weaning is not recommended. Talking can increase the work of breathing and fatigue the patient. It's better to focus on supporting their respiratory function rather than encouraging them to speak.

Administering a sedative before weaning

 Sedatives are typically avoided during weaning, as they can suppress respiratory drive and make it more difficult for the patient to participate in the weaning process. The goal is to assess the patient's ability to breathe on their own without the assistance of sedatives.

Summary:

To successfully wean a client from a ventilator, the nurse should prioritize actions such as weaning in the morning, limiting activities, and placing the patient in high-Fowler's position. These strategies help optimize the patient's respiratory effort and comfort, increasing the likelihood of a successful weaning process.

The correct answer is:  Suction the client.

Why this is correct:

Hypoxia in a Mechanically Ventilated Client: A pulse oximeter reading of 88% indicates significant hypoxia, which requires immediate intervention. 

Adventitious Lung Sounds: The presence of adventitious lung sounds (e.g., crackles, rhonchi, or wheezes) suggests that the client may have secretions or mucus obstructing the airway, which is a common cause of hypoxia in mechanically ventilated patients.

Suctioning: Suctioning the client’s airway is the priority action to clear secretions, improve oxygenation, and resolve the hypoxia. This is a standard nursing intervention for ventilated patients with suspected airway obstruction.

Why the other options are incorrect:

Contact the healthcare provider:

While contacting the healthcare provider may eventually be necessary, the nurse should first address the immediate issue (hypoxia due to possible airway obstruction) by suctioning the client. Delaying intervention to contact the provider could worsen the client’s condition.

Turn the client to one side:

Repositioning the client (e.g., turning to one side) may help with ventilation in some cases, but it does not address the likely cause of hypoxia in this scenario (secretions in the airway). Suctioning is the more direct and effective intervention

Silence the alarm:

Silencing the alarm without addressing the cause of the hypoxia is never appropriate. The alarm is alerting the nurse to a critical issue that requires immediate action. Ignoring it could lead to further deterioration of the client’s condition.

Summary:

The client is hypoxic (SpO2 88%) and has adventitious lung sounds, suggesting airway obstruction due to secretions.

The priority action is to suction the client to clear the airway and improve oxygenation.

Contacting the healthcare provider may be necessary later, but it is not the first step.

Repositioning the client is less effective than suctioning in this scenario.

Silencing the alarm without intervention is unsafe and neglectful.

By suctioning the client, the nurse can quickly address the cause of hypoxia and stabilize the client’s condition.

The correct answer is:  Presence of coronary artery spasm.

Why this is correct:

Stable angina is a clinical manifestation of coronary artery disease (CAD), which occurs when there is reduced blood flow to the heart muscle due to partial blockage or narrowing of the coronary arteries. This is often caused by atherosclerosis (plaque buildup) or temporary coronary artery spasm. The pain or discomfort associated with stable angina is predictable, typically triggered by physical exertion or emotional stress, and relieved by rest or nitroglycerin. Coronary artery spasm can temporarily reduce blood flow, leading to angina symptoms, even in the absence of significant atherosclerosis. Therefore, the presence of coronary artery spasm is a key feature of stable angina.

Why the other options are incorrect:

Associated with pulmonary disease:

This is incorrect because stable angina is a cardiac condition related to reduced blood flow to the heart, not a pulmonary (lung) condition. Pulmonary diseases, such as chronic obstructive pulmonary disease (COPD) or pulmonary hypertension, affect the lungs and respiratory system, not the coronary arteries.

Presence of a myocardial infarction:

This is incorrect because stable angina does not indicate an active myocardial infarction (heart attack). A heart attack involves complete blockage of a coronary artery, leading to irreversible damage to the heart muscle. Stable angina, on the other hand, involves temporary and reversible ischemia (lack of oxygen) due to partial blockage or spasm, without permanent damage.

Associated with renal disease:

This is incorrect because renal (kidney) disease is not directly related to the pathophysiology of stable angina. While renal disease can contribute to cardiovascular risk factors (e.g., hypertension, atherosclerosis), it is not a direct cause or indicator of stable angina.

Summary:

Stable angina is a condition characterized by predictable chest pain or discomfort due to reduced blood flow to the heart muscle, typically caused by coronary artery spasm or narrowing from atherosclerosis. The correct answer highlights the underlying mechanism of stable angina. The other options are incorrect because they either refer to unrelated systems (pulmonary or renal) or a more severe condition (myocardial infarction) that is not indicated by stable angina. Understanding the pathophysiology of stable angina is crucial for proper nursing care, including patient education, symptom management, and prevention of complications.

The correct answer is:  Respirations that are abnormally deep, regular, and increased in rate.

Explanation:

Kussmaul's respirations are a specific type of breathing pattern that is typically associated with metabolic acidosis, particularly diabetic ketoacidosis (DKA). These respirations are characterized by:

Deep, regular breathing that is faster than normal.

The body is trying to compensate for acidosis by exhaling more carbon dioxide (CO2) in order to raise the pH and reduce acidity in the blood. This type of breathing pattern occurs in response to metabolic acidosis, where the body attempts to balance the acidic environment by increasing the rate and depth of breathing, thereby expelling more CO2.

Why the Other Options Are Incorrect:

Respirations that are regular but abnormally slow.

This would describe bradypnea, which is slow, regular breathing. It is not characteristic of Kussmaul's respirations, which are fast and deep.

Respirations that are labored and increased in depth and rate.

This option sounds similar, but "labored" breathing is typically associated with respiratory distress, and Kussmaul's is more about increased depth and rate in a regular pattern. Labored breathing can involve difficulty or struggling to breathe, which is not the hallmark of Kussmaul's respirations.

 Respirations that cease for several seconds.

This describes apnea, where breathing temporarily stops. This is not characteristic of Kussmaul's respirations, which are continuous, deep, and regular.

Summary:

Kussmaul's respirations are deep, regular, and faster-than-normal breaths, often observed in conditions like diabetic ketoacidosis (DKA) as the body compensates for metabolic acidosis.

The correct answer is: Tachycardia

Explanation:

Isoetharine hydrochloride (Bronkosol) is a bronchodilator that is commonly used for treating conditions like asthma and chronic obstructive pulmonary disease (COPD). It works by relaxing the smooth muscles of the airways, helping to open them up for easier breathing. However, as a sympathomimetic drug, it can stimulate the heart, leading to tachycardia (an increase in heart rate).

Why the other options are incorrect:

Constipation

Isoetharine is not known to cause constipation. The more common side effects are related to cardiovascular stimulation and the respiratory system.

Diarrhea

Diarrhea is not a typical side effect of isoetharine. The drug is more likely to affect the cardiovascular system, such as causing tachycardia, rather than the gastrointestinal system.

 Bradycardia

Bradycardia (slow heart rate) is not typically associated with isoetharine. In fact, as a sympathomimetic, isoetharine is more likely to increase heart rate, resulting in tachycardia, not slow heart rate.

Summary:

When administering isoetharine hydrochloride (Bronkosol), the nurse should monitor for tachycardia as it is a common side effect of this bronchodilator due to its sympathomimetic properties, which can increase heart rate.